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Appearances can be deceiving: aging, homelessness, and acute care

Before reading any further, stop to think about the last
older homeless adult you saw. If you are a clinician – think of the last older
homeless patient you cared for – if you can remember the last time you had such
an encounter in acute care settings such as the ED or hospital, even better.

Does this person you remember look anything like the
gentleman pictured here?

Probably not...

...but here’s the catch: the odds are very good
that you've met someone (maybe even provided clinical care for someone) who was
without a home but you didn't know it because they didn't “look homeless.” In a study published this month in the Journal of Healthcare for the Poor and Underserved
(JHCPU), my colleagues and I described the experience of acute care from the
perspective of 100 homeless individuals seen in the ED or hospitalized over a 1
year period in New Haven, CT. We found that only 2 in 5 were ever asked about
their housing status during the course of their care at the hospital. Not
surprisingly, those who were asked were several times more likely to receive
high-quality discharge planning based on their needs (e.g. discussions about
costs of medications and transportation). Compounding the problem of using the
“eyeball test” to determine who has unstable housing, many patients are
hesitant to disclose their need for fear of discriminatory care or simply from
embarrassment – this may be particularly true for older adults.

Our results were the result of a community-based
participatory research project with Yale-New Haven Hospital and Columbus House, a robust homeless services organization
that operates 2 large shelters in New Haven. Leveraging the strengths of
this unique partnership, we also found that lack of coordination between the
hospital and shelter was a major barrier to successful transitions for
patients. As one patient explained, “miscommunication is a problem – sometimes
the hospital sends you to the shelter, but you can’t get in.” Indeed almost 1
in 3 patients were discharged after dark and 1 in 10 spent their first night
after discharge on the streets. Fortunately, data from this project led to a
community taskforce including the hospital, shelter, city and state government
to develop a respite care unit within the shelter for homeless patients
requiring special care after discharge (such as daily wound care or IV
antibiotics). A bill supporting
this project passed the Connecticut State Legislature in Month and the respite
unit will open this fall.

Many cities like New Haven are joining the movement to
increase access for homeless patients to respite care after hospitalization
both for reasons of quality improvement and cost reduction. In a systematic
review also published this month in JHCPU by Kelly Doran, current
Robert Wood Johnson Foundation Clinical
Scholar at Yale and leader in the New Haven Respite Taskforce, shows that
respite programs consistently reduce the length of hospital stays, hospital
readmissions, and overall costs of care for homeless adults. Despite these encouraging results, there is
still work to be done. Although the mean ages of patients enrolled in the 13
studies analyzed in this review were in the mid-to-late 40s, there were no
respite studies with resources specifically geared for older homeless adults.

As the homeless population continues to age, improving the
quality and continuity of care for homeless adults is becoming ever more
important. As my colleague Rebecca Brown
points out in a study published this week in JAMA Internal Medicine, the
average age of homelessness has increased from 35 to 50 over the last 20 years
and older homeless adults access acute care services at extraordinarily high
rates. In a cohort of 250 older homeless adults in Boston, 2 in 3 visited the
ED in the last year and almost 1 in 3 visited the ED 4 or more times. The
presence of geriatric syndromes such as falls and impaired executive function
were powerful predictors of frequent ED use. In another study
published this month in JHCPU, she also demonstrates that even the “younger” adults in
this “over 50” cohort are at high risk for these geriatric syndromes.

These findings have important and unfortunate implications
for these patients as well as our healthcare system – an ED clinician looking
at a 55 year old man with an injury or musculoskeletal complaint might not
think to ask if he is homeless and might not consider the patient’s risk for
geriatric syndromes. In medicine, appearances may be deceiving but this
shouldn't prevent clinicians from making a difference for this population.
Patients in our community-based study recommended that clinicians take a
simple, patient-centered approach to assessing housing needs: rather than ask
patients who “look homeless” the usual, pointed questions of “are you
homeless?” or “do you have a permanent address?” acute care providers can
simply and compassionately ask all their patients, “do you have a place to stay
where you feel safe?” Personally
speaking, I probably would never have guessed the gentleman pictured above – a
former client at Columbus House shelter in New Haven – was homeless if I had met
him in a busy Emergency Room. To provide the best possible care for this highly
vulnerable population of seniors, our first and perhaps greatest challenge
might just be to look past our preconceived notions to learn who these
patients are.

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